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mx
Revista Mexicana de Ortodoncia
Vol. 6, No. 1 January-March 2018
pp 20-25
Prevalence, types and etiologic factors of mandibular crowding
in orthodontic patients in Tabasco, Mexico, 2015-2016
Prevalencia, tipos y factores etiológicos de apiñamiento mandibular tardío en
pacientes de ortodoncia en Tabasco, México, 2015-2016
Maury Gabriela González Amaral,* Luz Verónica Rodríguez López§
ABSTRACT
Late mandibular crowding is a frequent malocclusion that develops
between 15 and 20 years of age and has been associated with
a number of etiological factors, mainly: the eruption of lower
third molars, anterior tooth discrepancy, mandibular length and
growth pattern. The aim of this investigation was to evaluate the
prevalence, types and etiological factors of late mandibular crowding
in orthodontic patients, in Tabasco, Mexico, 2015-2016. It was an
observational, analytical, case-control study. The sample consisted
of 74 new patients from the Postgraduate Clinic of Orthodontics of
the Juárez Autonomous University of Tabasco who came to the clinic
between August 2015 and December 2016. Clinical records, models
and radiographs were reviewed. It was found that the prevalence of
late mandibular crowding was 83.7%; the most common types were
severe 26% and very severe 27%. Seventy percent of the patients
showed more dentoalveolar discrepancy on the lower arch. Twenty
six percent of patients with crowding showed reduced mandibular
length. The horizontal growth pattern predominated in 49% of the
case groups and in 58% of the controls. The C position of the third
molars predominated on both sides. It was concluded that no patient
with crowding had a diminished mandibular body or a vertical growth
pattern. Crowding can occur regardless of whether or not the lower
third molars are present.
Key words: Prevalence, crowding, etiology.
Palabras clave: Prevalencia, apiñamiento, etiología.
INTRODUCTION
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Dental crowding is a very frequent malocclusion
that has been present in humanity for centuries. It
is defined as the discrepancy between teeth size
and the available space for their correct functional
and aesthetic position, which may affect oral health
by increasing susceptibility to dental caries and
periodontal disease, with repercussions on the dental
and facial aesthetics of the patients. It is one of the
main reasons for consultation of patients.1
According to its severity, it is classified as mild,
moderate, or severe, however Van der Linden, classified
ORIGINAL RESEARCH
RESUMEN
El apiñamiento mandibular tardío es una maloclusión frecuente que
se desarrolla entre los 15 y 20 años de edad, y que se ha asociado
con diversos factores etiológicos, principalmente, a la erupción de
los terceros molares inferiores, así como la discrepancia dentaria
anterior, la longitud mandibular y el patrón de crecimiento de la mis-
ma. El objetivo de la presente investigación fue evaluar la prevalen-
cia, tipos y factores etiológicos de apiñamiento mandibular tardío
en pacientes de ortodoncia en Tabasco, México, 2015-2016. Fue
un estudio observacional, analítico, de casos y controles. La mues-
tra se conformó por 74 pacientes de nuevo ingreso de la Clínica
de Posgrado de Ortodoncia de la Universidad Juárez Autónoma de
Tabasco, entre agosto del 2015 y diciembre del 2016. Se revisaron
expedientes clínicos, modelos y radiografías. Se obtuvo que la pre-
valencia de apiñamiento mandibular tardío fue de 83.7%, los tipos
más comunes fueron el severo 26% y muy severo 27%. El 70% de
los pacientes presentó mayor discrepancia dentaria anteroinferior.
26% de pacientes con apiñamiento mostraron longitud mandibular
reducida. El patrón de crecimiento horizontal predominó en grupo
de casos con 49% y en grupo control con 58%. La posición C de
los terceros molares predominó en ambos lados. Se concluye que
ningún paciente con apiñamiento presentó un cuerpo mandibular
disminuido ni patrón de crecimiento vertical. El apiñamiento puede
presentarse independientemente de si están o no presentes los ter-
ceros molares inferiores.
* Student.
§
Full-time research professor.
Orthodontics Specialty, PNPC, Academic Division of Health
Sciences, Juárez Autonomous University of Tabasco.
© 2018 Universidad Nacional Autónoma de México, [Facultad de
Odontología]. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
This article can be read in its full version in the following page:
http://www.medigraphic.com/ortodoncia
Revista Mexicana de Ortodoncia 2018;6 (1): 20-25
crowding depending upon the time at which it appeared
in the dentition, thus establishing the classification in
primary, secondary and tertiary crowding. The latter is
that which develops between 15 and 20 years of age,
also known as late dental crowding, since it occurs in
the mandibular incisors during adolescence and the
period after. Its etiologic factors range from genetic to
local.2 However, it has been associated mainly with the
eruption of the lower third molars, followed by other
factors such as tooth mass ratio, mandibular length and
mandibular growth pattern.3
Mesiodistal size of tooth crowns influences the
development of this malocclusion. The literature
mentions that in the last few decades there has been
a trend toward the reduction of the mandibular base
size without a decrease in the size of teeth, making
it necessary to perform extraction or interproximal
reduction treatments.4 Puri and colleagues conducted
a study to determine if biometric dental size contributed
to crowding. They found that in the group with poor
alignment, the teeth were significantly wider compared
to the control group.5
With regard to mandibular length, cephalometric
studies have determined that when a mandible has
poor growth and reduced body length, there is greater
incisor retroclination and verticalization, which leads
to an increase in lower anterior crowding. Janson and
colleagues conducted a study focused on verifying the
relationship between mandibular length and dental
crowding, finding that the decrease in the mandibular
length is an important factor associated with dental
crowding.6
Relevant to mandibular growth pattern, the literature
shows that the more vertical growth is, more eruption
of the incisors to compensate for the vertical space
created; this eruption decreases the likelihood to
maintain contacts between the teeth and thus, the risk
of crowding increases.7
In relation to third molars and their possible influence
on the development of lower anterior crowding, it
has not been clarified in the dental literature if these
teeth are conducive or not to this anomaly. There is a
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Table I. Prevalence of late mandibular crowding by gender.
Patients n %
With crowding 62 83.7
Without crowding 12 16.2
p = χ2 test.
Source: direct.
21
debate among clinicians who support the removal of
third molars as a preventive measure and those who
do not.8
Being a malocclusion that affects both the smile
aesthetics as well as the proper function of the
masticatory system, one that can be expressed in
different degrees of severity and is associated with
several risk factors, the need to know the magnitude
of this problem in the state of Tabasco arose. The aim
was that at the moment of establishing a diagnosis
and treatment plan, the clinician may choose the
therapeutic alternative that can best be used for the
correction of this anomaly and to be able to provide
the patient acceptable aesthetics with correct function,
which is the main desire of the patient and of every
ethical and responsible clinical institution. Therefore,
the main objective of this research was to evaluate
the prevalence, types, and etiologic factors of late
mandibular crowding in orthodontic patients, in
Tabasco, Mexico, from 2015 to 2016.
MATERIAL AND METHODS
This was an observational, analytical, cases and
controls study. The universe was composed of 200
patients of the Orthodontic Post-Graduate Program
of the Juarez Autonomous University of Tabasco who
attended the clinic from August 2015 until December
2016. A non-probabilistic sampling for convenience
was selected. Seventy-four patients constituted the
sample. Their clinical records, models and panoramic
and lateral headfilm radiographs were reviewed. The
group of cases was composed of 62 patients, all
with late mandibular crowding; and the control group
comprised 12 patients, which had a perfect alignment
or spaces between teeth (Table I).
The following inclusion criteria were determined:
patients without previous orthodontic treatment,
with complete permanent dentition, 15 years of age
and older, healthy and whose clinical records were
in excellent conditions; with radiographs and study
models in optimal conditions.
Male Female
n % n % p
16 84.2 46 83.6 0.95
3 15.7 9 16.3
 González AMG et al. Prevalence, types and etiologic factors of mandibular crowding in orthodontic patients
22

Patients were excluded if they had had previous
orthodontic treatment, had primary or mixed dentition,
extractions; patients with dental anomalies of shape,
size and number; patients under 15 years of age, with
syndromes or cleft lip and palate and those patients
whose clinical records, study models and X-rays were
not in optimal conditions.
In the lateral headfilms, we identified the following
anatomical points: gonion nasion, sella, and menthon,
which are necessary to measure the mandibular
base length (Go-Me), anterior face height (N-M) and
posterior face height (S-Go). When performing the
percentage relationship between these last two the
growth pattern of the patient was obtained according
to Jarabak. From panoramic radiographs we observed
those who had third molars and those that did not;
we analyzed the position of the lower third molar
with respect to the second molar, as indicated by the
classification of Pell and Gregory.
With the study models we calculated the severity
of the dental crowding according to Little’s Irregularity
Index, for which we performed a linear measurement
of the contact points’ displacement of each of the
four mandibular incisors; starting from the contact
point between right canine and lateral incisor up until
the left lateral incisor and the contact point with the
left canine, thus obtaining five segments. The sum
of these five segments represents the degree of
irregularity that the incisors of the patient have. There
are five ways to classify it: when the sum of the five
segments is equal to zero, the patient has a «perfect
alignment»; when the sum ranges between one and
three millimeters, it is said that the irregularity is mild;
a summation of four to six millimeters is classified
as amoderate irregularity; a sum of seven to nine
millimeters is considered a severe irregularity and
a sum of more than 10 millimeters would be a very
severe irregularity.9
The collected information was introduced in a
database designed in Excel (Microsoft). Using the
respected, in accordance with the Nuremberg Code
and the Declaration of Helsinki of the World Medical
Association. The investigation was conducted by the
interests of science and society and not for the welfare
of third parties.
RESULTS
The total study sample were 74 clinical records and
diagnostic models; 55 were female, representing 75
per cent and 19 were male, representing a 25% of the
sample. With respect to age, 54 patients were found
within the range of 15 to 20 years, which represented
73% of the sample; 16 patients were between 21 and
30 years, (22%) and 4 patients were older than 30
years (5%).
The χ2 test determined that there was no statistically
significant difference between late mandibular
crowding by gender.
Figure 1 shows the types of dental crowding found
in the study sample according to gender using Little’s
classification. When the χ2 test was performed, it was
determined that there was no statistically significant
difference between the type of late mandibular
crowding in relation to the gender.
The χ2 test found a statistically significant difference,
which indicates that there is a relationship between the
presence of an excess of lower anterior tooth mass and
the development of late mandibular crowding (Figure 2).
The χ2 test revealed that there was no statistically
significant difference, which indicates that there is no
relationship between mandibular body length and late
mandibular crowding (Figure 3).
p = 0.9697
30 27
26
25 24
21 22 21
20
Percentage

same program or the statistical package SPSS 16 16 16

(Statistical Product and Service Solutions) 2.2 version, 15

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we performed the descriptive statistics, proportions for
qualitative variables, measures of central tendency
10
11

and dispersion for the quantitative variables. χ2 tests 5

were carried out to find the statistical relationship
0
between variables. The results are presented in Perfect Mild Medium Severe Very severe
frequency tables and graphs. alignment irregularity irregularity irregularity irregularity
The predictable risks and the potential benefits of Male Female
the research were considered and we had the written
p = χ2 test.
informed consent of each of the patients, which was Direct source.
signed at the start of treatment. Freedom to leave
the study when the patient so wished was given and Figure 1. Crowding types according to gender.
 Revista Mexicana de Ortodoncia 2018;6 (1): 20-25
23

Upon performance of the χ2 test, it was found no
statistically significant difference, which indicates that
there is no relationship between the growth pattern and
development of late mandibular crowding (Figure 4).
No statistically significant difference was found;
there may or may not be lower anterior crowding,
regardless of whether or not the third molars are
present and their position (Figure 5).
No statistically significant difference was found;
there may or may not be lower anterior crowding,
p = 0.002
80
70
70
60
50
Percentage
regardless of whether or not the third molars are
present and their position (Figure 6).
DISCUSSION
The present study determined that the prevalence
of late dental crowding was 83.7% (n 62); the most
common crowding types type were severe and very
severe, with discrepancies ranging from 7 to 9 mm
and 10 mm respectively. Lakhani and collaborators
reported a slightly lower prevalence of 61%, but with
crowding types with irregularities from 5 to 10 mm; the
mean age was 17.5 years.10 Qutub and collaborators
obtained a prevalence of 59.9%, finding milder
crowdings that ranged between 3 and 4 mm.11
By studying tooth discrepancy through the Bolton
index, it was determined that in patients with and
without crowding there is an excess in lower anterior

42
40 dental mass, which indicates that the dimensions of
33 the lower crowns are larger in relation to the upper. In
30 26 25
Este20documento es elaborado por Medigraphic the group with crowding this was observed in 70% of
patients, whereas in the control group it was 43% thus
10 coinciding with Bugaighis and Elorfi, who obtained in
3
0 their study that the coronary dimensions of mandibular
With crowding Without crowding teeth were larger in patients who had dental crowding
in comparison with patients with normal occlusion and
Lower anterior tooth material excess Adequate Proportion diastemas.12 Likewise, Bansal and collaborators found
Upper anterior tooth material excess a correlation between the size of teeth and dental
p = χ2 test.
crowding: the larger the tooth size, the more severe
Direct source. the malocclusion would be; and the smaller, there
would be more diastemas between the teeth.13
Figure 2. Dental discrepancy with and without late We found a statistically significant difference
mandibular crowding. that demonstrates the relationship between excess

p = 0.09 p = 0.52
70 70
58
60 58 60
52 49
50 50
41 42
Percentage

42
Percentage

40 40

30 30

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26
21 20
20
10
10 10
0
0 0
0
With crowding Without crowding
With crowding Without crowding
Vertical Neutral Horizontal
Increased Normal Decreased
Direct source. Direct source.

Figure 3. Mandibular body length and late mandibular crow-

ding. Figure 4. Growth pattern and late mandibular crowding.
 González AMG et al. Prevalence, types and etiologic factors of mandibular crowding in orthodontic patients
24
in tooth mass and late mandibular crowding: the
larger the mesiodistal dimension of the lower teeth,
the greater predisposition to this malocclusion will
be. This statement coincides with Santiesteba et
al, who demonstrated that as dental crowding gets
worse from mild to moderate, the size of the dental
mass also increases. When they compared the size
of the tooth mass in mild crowding with that present
in the moderate and severe forms, they found that
statistically they were not equal.14
With regard to mandibular body length, it was
observed that in both groups there is a greater number
of patients who have a normal mandibular length,
52% in patients with crowding and 58% in the control
group. However, among patients without crowding
any presented a decreased mandibular body, the
size of their mandibles was in norm or increased. Ijaz
and collaborators claim that the length of the basal
bone is directly related to the amount of crowding,
regardless of the type of malocclusion. In addition to
the size of the crowns, mandibular length is a factor
that must be considered during the treatment because
if a patient has mild to moderate crowding and at the
same time it is noted that the crown proportions are
large, thenit is most likely to follow a treatment with
interproximal reduction or expansion. However if the
patient presents moderate to severe crowding, and the
crown dimensions are adequate, it is likely that this
patient needs extractions.15 On the other hand, Khoja,
Fida and Shaik, argue that the increase in crowding
severity of the dental arch is weakly associated with
the lengths of the mandibular base, but there is a
50
45
42
40
Percentage
30
19 18
20 18 17 17
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10
0 0
With crowding Without crowding
Position A Position B Position C
p = χ2 test.
Direct source.
Figure 5. Presence of right lower third molar and its position
in patients in patients with and without crowding.
moderate positive correlation between the lengths of
the base of the mandible and crowding in this arch.16
No study was found in the last five years that
relates the variables of mandibular growth pattern and
lower anterior crowding using the index of irregularity
of Little.
As to the position of the left and right third molar, the
position that prevailed was located below the crown of
the second molar. It was observed that in the control
group of the left and right side, the absence of the third
molar was greater than in the group with crowding;
however the difference was minimal, thus it is safe to
say that lower anterior crowding can occur regardless
of whether or not lower third molars are present.
These results coincide with those of Hasegawa and
collaborators, who showed that there was not a close
relationship between the position of the third molars
and lower anterior crowding as determined by Little’s
irregularity index. Likewise, Esan and Schepartz,
determined that the presence of third molars is not
associated with lower anterior crowding, since they
had patients with agenesis of this tooth and presented
this malocclusion. In against part Cherian and Ravi,
were able to demonstrate that the presence of the third
molar does have an influence on the development of
lower anterior crowding and that the morphological
characteristics of the patient were not significant.17
CONCLUSIONS
The development of late mandibular crowding is a
consequence of the combination of several factors.
p = 0.1949
p = 0.776
60
50
50
44
40
Percentage
25
30 25
21
19
20 16 17
8
10
With crowding Without crowding
Position A Position B Position C Absent
Absent
p = χ2 test.
Direct source.
Figure 6. Presence of the left lower third molar and its
position, in patients with and without crowding.
Revista Mexicana de Ortodoncia 2018;6 (1): 20-25
The knowledge of these factors and the influence
of each one of them are necessary because it helps
determine the best treatment for the patient. With
regard to the influence of the position of the lower
third molar it was determined by means of this study
that regardless of its presence and position in the
mandibular bone, the third molar does not have an
influence on dental crowding, as this malocclusion was
observed in patients who had this tooth and in patients
with agenesis.
The finding of this investigation with respect to the
influence of the lower third molar provides a scientific
ground regarding the management of these teeth. In
spite of the literature that revolves around this theme,
it does not clarify the issue of whether or not the third
molar should be extracted for being a causal agent of
crowding.
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Mailing address:
C.D. Maury Gabriela González Amaral
E-mail: dra.maurygomaral@gmail.com